12110096 CITY OF CUPERTINO BUILDING PERMIT
BUILDINCADDRESS: 20677GARDI3NSIDECIR CO\FRACfOlt: 13ATIiROOMS BY PERMITN'0: 12110096
REMODELING
OWNICR'S NAME: CIIER17AOUI MOURAD AND KI-IELIPA I IASSIB 1422 SARA'I'OCA AYE DA'Z'E ISSUED: 11/15,2012
ONV,NFR'SPIIONE: 4083688612 SAN,IOSE,C\ 95129 PDONF,NO:(a08)378-6700
❑
LICENSED CO.\I'RACfOR'S DECLARATION
r
BUILDING PERM IT INFO: BLDG r ELECT PLUMB r
License Class Lie.N 1J 02 3 r r r
S� oµs nH
Contractor �IECFI RERESIDENTIALcoMhYIERc1AI.
OrroA4(a.y� SWC. Data
1 hereby affirm that I am licensed undei the provisions of Chapter 9 JOB DESCRIPTION: BATHROOM RENIODEL NON STRUCTURAL•
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and [[tat my license is in full force and effect.
I hereby affirm under penally of perjury one of the following too declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
Sq.FI Pluar,\n•:m: Valuation:511400
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued AL'N Number:36232019.00 Occupancy Type
APPLICA\I'CERTIFIC\TION -
1 certify that I have read this application and state that the above information is
correct. l agree to comply with all city and count'ordinnces:md state laws relating PERMITEXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indenutify and keep harmless the 6ty ol'Cupenitio against liabilities,judgirterris, I80 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
grunti4poim
'\dditionally,the appl' understands and will comply
with aceCreguliper the Cupenn Municipal Code,Section Issued bv' L-
9.18.
Signa Datc �Z—
RP,ROOFS:
❑ OWNISR-BUILDER DECLARATION All roofs shall he inspected prior to any rooting material being installed. ll'a rnoris
installed without first obtaining:in inspection.I agree to'renhovc all new materials lit
1 hereby folio a(lg t that far exempt from the Contractor's License hna'for one of inspection.
the following two reasons:
1,a;owner of the propcny,or my employees with wages as their sok compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business B Professions Code)
I,as owner of the propcny,am exclusively contracting with licensed contractors to ALL ROOF COYERINCS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business C Professions Code).
1 hereby affirm under penally of perjury one of the following three IIA%ARDOUS\LYIT1tIALS DISCLOSURI
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 ollhe
I have and will maintain a Ceniftcate of Consent to self-insure for Worker's California Heald,&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided I'or by Section 3700 of the Labor Code,liar the compliance with the Caperlino Municipal Code.Chapter 9.12 and the 1leath
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area.Mir Quality Msnagemem District I will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health C Safely Code.Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to die Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate ofexcmption,I Dae
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deenhed revoked CONSTRUCHON LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perlonnance or work's
APPLICA\l'CF.R'II FICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state lases relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the Cit'ofCupenino against liabililics,judgments,
costs,and expenses which may Tacoma against said City in consequence of the ARCI1f Fif-I-S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CONSTRUCTION PERMIT APPLICATION
(///�
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION,/"
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 -
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building0cuoertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED
p/ORIGINAL PERMIT"
PROTECT ADDRESS .9 ^67� C^�C-- /S J n APNB s4 �O 19
OHMERyglfyrat) Cfl�Yz-r-A OU ) p
//,,//((// PHONE �- 36� �n // E-MAIL
STREET O/^ L's _ Q 0 Jp- CITY, 5T 7E,ZIP /�U tl b �I I FAX
CONTACT NAME Gn'CY- oV PHONE. jam/ E-MAIL
J�j -70 e US
STREET DD '�Z_ (� CITY,STATE ZIP— FAX
O OWNER ❑ OWMJLBUILDER ❑ OWNERAGENT fft CohTRACTOR OCON-PACTORAGENT O ARCHITECT O ENGINEER O DEVELOPER ❑ TENANT
CONTRACTOR NAME C)Zo ��v—A LICENSE NUMBER 7(fO LICENSE TYPE Cr I BUS.LTC C
COMPANYNMIE E-MAIL 1 , FAX
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STREET ADDRESS - CITY,S1',A�✓P L ""'fro?
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ARCHITECTIENGLNEER NAME LICENSE NUMBER BUS.LIC 9
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY,STATE,ZIP I PHONE
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DESCRIPTION OF WORT:
EXISTING USE PROPOSED USE CONSTATYPE =STORIES
USE TYPE OCC. sQ.1-1'. VALUATION(S)
MSTG NEW FLOOR DEMO TOTAL /
AREA AREA AREA NET AREA S(� I✓a r d / ciO o
BATHROOM IU'TCHEN OTHER 1
REMODEL.AREA REMODEL AREA REMODEL AREA
PORCHAREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
M DWELLING UMTS: ISASECONDUNIT OYES SECONDSTORY OYES
BELNGADDEDt ONO ADDITION! ONO
PRE-APPLICATION OYES IF YES,PROVDE COPY OF ISTHEBLDGAN ❑YES RECEI VEIDY.O.H , m}% ' # TOTAL VALUATION:
N
PLANNGAPPLd OAP
NO PLANNING PROVAL LETTER EICHLERHOMEe OT' "�NO r+'l.'$' = G= F�`�
rt ��
By my signature below,1 certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the informational haveprovided is correct. I ve read the Descripuon of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating g cO istructio 1 authorize representat of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicandAgerrtu Date:
SUPPLI�Iv[ENTORI1dATION REQUIRED PL.af` ;cit e"l r a.- 3 F�oU4T1aGG;sutP .
New SFD or Multifamily vellings: Apply for demolition permit for MIR" t` "1iv�T1,11
�T"HF COU\TI Rcy�H 'ItUlliDl\C I'LALRE\TFw
existing buildine(S). Demolition permit is required prior to issuance of building �,.Y� n �� 'ri -• m _ • - T
permit for new building, ti0 EXI Ress � t TLA,\\'1\arias REtnEtw e1
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 5. STkNDARn�,J sy'',-"'�- ❑a-rruauCatows �i
form if any Hazardous Materials are being used as par[of this project. -
S❑rFLARGE �, t�+SrL Y' O FIRb DEIT F'
_Copy of Planning Approval Letter or Meeting with Planning prior to PFS` • , a` fra, y� .,,
2 _ ❑A SSANITARY SE\l EIt m$TRICT
submittal �
al of Building Permit application. � cr
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Bldg9pp_2011.doc revised 06121111
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Bathrooms by Remodeling Specialists
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CITY OF CUPERTINO
®R FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 20677 gardenside circle. DATE: // 1 oZ REVIEWED BY: bobs.
APN: BP#: /QW& 'VALUATION: $11,400
*PERMIT TYPE: Plumbing Permit PLAN CIIECR TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1RPFIX
USE: PERMIT TYPE: At
WORK sfd bath remodel non structural.
SCOPE
APPLIANCE/EQUIP TYPE 'FEE ID QTY UNITS BP FEES
Fixture or Trap 16PFIXTURE 3 # $30
TOTALS: $30.00
rNerh. Plan'Check Plumb. Plan Check "00 $0.00 Flec.Plan Check '
,Neth.Permit Fee: Plumb. Permit Fee: IPPERMIT F:/cc.Permit Fee:
Oeher Sfech../nsp. Other Plumb Insp. 0.0 hrs $45.00 Other Flcc.bap. Li
,1•lech.hap.Fee: Plumb. lusp. Fee: rice./esp. Fee:
NOTE: This eainrette does not includejees due to other Departments(i.e. Planning, Public (Yorks, Fire,Sanitary Sewer District,School
District,etc.). These fees are hased on the prefindnat3 information available and are only an estimate. Contact the Dept for aeldn7 info.'
FEE ITEMS (Fee Resolution 11-053 EB: 7/I/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
PME Plan Check: $0.00
Perinit Fee:
-
Suppl. lusp Fee
PME Unit Fee: $30.00
PME Permit Fee: $45.00
Consa•uction Tar:
Administrative Fee: IAWHN $42.00
Work Without Permit? 0 Yes Q No $0.00
Advaizeed.Plumiing Fees:
,Travel Documentation Fee: ITRA VDOC $45.00
Strom Motion Fee: IBSFISh1ICR $1.14 Select an Administrative Item
Bide Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $164.14 $0.00 TOTAL FEE: $164.14
Revised: 10/01/2012